Skin Tear Prevention

1. Skin Tear Prevention Bruising or Ecchymosis

2. Parameters of assessment • Category I: • Skin tear WITHOUT tissue loss • Category II: • Skin tear WITH partial tissue loss • Category III: • Skin tear with COMPLETE tissue loss, where the epidermal flab is absent

3. Strategies and Interventions • Prevention is #1 intervention! • Provide a safe environment • Perform risk assessment of elderly patients on admission • Implement prevention protocol for patients identified as AT RISK FOR skin tears and bruising of skin • Patients can wear long sleeves or pants to protect their extremities (if appropriate and applicable) • Have adequate light to reduce the risk for bumping into furniture or equipment • Provide a safe area for wandering

4. Educate staff or family caregivers • On the correct way of handling patients to PREVENT skin tears • Maintain nutrition and hydration status (if applicable) • Offer fluids between meals (unless contraindicated) • Use lotion, especially on dry skin – arms, legs, BID • Obtain dietary consult (if indicated) – consult with your primary nurse

5. Protect skin from self-injury or injury during routine care • Use a lift sheet (draw sheet) to move and turn patients • Use transfer techniques that prevent friction or shear • Pad bedrails, wheelchair arms, and leg supports • Support dangling arms and legs with pillows or blankets

6. Use non-adherent dressings on frail skin • Apply petroleum-based ointment, steri-strips, or a moist non adherent wound dressing such as hydrogel dressing with gauze as a secondary dressing (if ordered, indicated and within your scope of practice) telfa type dressings can also be used • If you must use tape, be sure it is made of paper and remove GENTLY. Also, you can apply the tape to hydrocolloid strips placed strategically around the wound rather than directly onto fragile surrounding skin around the skin tear

7. Protecting skin continued • Use gauze wraps, stockinettes, flexible netting, or other skin protective measures to secure dressing rather than tape • Use no-rinse soapless bathing products (if indicated) • Keep skin from becoming dry, apply moisturizer (if indicated)

8. Treating skin tears • Gently clean the skin tear with normal saline • Let the area air dry or pat dry carefully • Approximate the skin tear flap (if indicated) • Use caution if using film dressing as skin damage can occur when removing dressing • Consider marking an arrow on skin tear dressing to indicate the direction of the skin tear to minimize any further skin injury during removal

9. Ambercare’sreporting policy • When you identify that your patient has bruising and/or skin tears on integument please follow the following protocols: • Notify supervisor that a skin tear has occurred by you (via phone) • Notify facility charge nurse (or primary nurse) the occurrence • Fill out incident report form (for QA tracking and trending) and give to supervisor (Joanne) • Document occurrence accurately and thoroughly

10. References • www.hhs.gov • US Department of Health and Human Services • www.guideline.gov • www.ahrq.org